EAST-AFNET 4 Early Rhythm Control — EECC MCQ

Correct answer: A — EAST-AFNET 4 showed that early rhythm control (within 12 months of AF diagnosis) using antiarrhythmic drugs and/or catheter ablation reduced cardiovascular death, stroke, and HF hospitalisation compared with standard rate-control-first management — supporting a paradigm shift toward early rhythm control

EAST-AFNET 4 (2020) was a practice-changing trial: 2,789 patients with recently diagnosed AF (≤12 months) randomised to early rhythm control (AAD and/or catheter ablation) vs usual care (rate control first, rhythm control only for persistent symptoms). Results: early rhythm control reduced the composite of CV death, stroke, and HF/ACS hospitalisation by 21% (HR 0.79, p=0.005). This challenged the longstanding paradigm from AFFIRM/AF-CHF that rhythm control offered no advantage over rate control. Key differences from earlier trials: (1) EARLY intervention (within 12 months of diagnosis, not after years of AF); (2) safer tools (ablation, flecainide — lower toxicity than amiodarone-heavy regimens of AFFIRM era); (3) modern anticoagulation (continued regardless of rhythm — avoiding the fatal flaw of stopping OAC after cardioversion in earlier trials). The 2024 ESC AF Guidelines now give early rhythm control a Class I recommendation.

Reference: ESC (2024): AF Guidelines; EAST-AFNET 4 Trial